The digital determinants of liver disease
Authors: Sharad I. Wadhwani, Jennifer C. Lai
Journal: Hepatology (2022)

Telehealth has been heralded as an opportunity to mitigate health inequities by enabling patients to overcome structural barriers to seeking health care.1 Structural barriers, such as the inability to secure time off of work or high transportation costs, add additional burden to patients with liver disease2 and may contribute to observed inequities in outcomes.3 Prepandemic, telehealth was a promise rather than a reality, with robust telehealth infrastructure available at select health systems despite patient preference for telehealth options.4 The pandemic forced the US healthcare system to rapidly adopt telehealth as an important tool for delivering healthcare. Given this rapid uptake, telehealth has been identified as an important tool for treating patients with end‐stage liver disease that may improve patient access and allow for more equitable care delivery.5 However, in this month's issue of Hepatology, Henson and colleagues6 report dismaying data refuting the promise of telehealth to improve access and narrow disparities in liver disease. The authors evaluated county‐level associations among liver‐related mortality, broadband availability, and access to a gastroenterologist/liver transplant center. The authors found that counties with decreased access to gastroenterologists and liver transplant centers had increased county‐level liver‐related mortality. These counties tended to have residents who were more likely to be living in poverty, have lower educational attainment, have less access to primary care, and be living in a rural location. These same counties were less likely to have access to the high‐quality connectivity necessary to engage in telehealth appointments, demonstrating that telehealth in its current iteration will be unable to overcome health inequities in liver disease. For telehealth to be a viable solution to overcoming disparities in liver‐related mortality, the United States will need to tackle the "digital divide." This study adds to the growing body of hepatology literature demonstrating that structural factors impact liver disease outcomes. These structural barriers include diminished economic opportunities, decreased access to primary care, food deserts, and increased exposure to environmental pollutants. For example, our group has documented that living in socioeconomically deprived neighborhoods and in areas with primary care shortages negatively impact outcomes after pediatric liver transplantation.7,8 This study extends this literature by highlighting a newer social determinant of health: digital access. Indeed, with the rapid implementation of telehealth capacity over the past 2 years, several patient‐level, health system, and structural barriers to implementing this technology equitably have emerged.9 Thus, to realize the promises of telehealth benefiting the most vulnerable patients, we must overcome barriers to its widespread use. No single strategy will bridge the digital divide; rather, several complementary strategies should be developed to address the barriers to telehealth in hepatology at the levels of the patient/family, health system, and US policy.10 Patient/family level. Hepatology clinics must identify ways to overcome poor digital health literacy and readiness. Video visit portals may not be easily accessible for those with limited digital health literacy and may put this technology out of reach for certain groups. Thus, as health systems seek to make these platforms widely available, they must account for varying levels of digital health literacy. For example, digital health navigators,11 clinic staff who can help patients download, log in, and successfully complete a virtual visit with their hepatologist, may enable more inclusivity of telehealth in hepatology. Health system level. Liver transplant centers should seek to strengthen community partnerships and improve hepatology access for underserved and at‐risk geographic areas within their catchment area.12 Such work may include partnerships with local health centers to provide in‐person support for digital health literacy challenges or lack of broadband technology. For example, hepatology clinics could partner with distant primary care practices so that patients could conduct their telehealth appointment with a remote hepatologist virtually in their primary care physician's office. US policy level. The hepatology community must advocate for policies that enable equitable access to telehealth technology for their patients. It is estimated that 21 million people in the United States lack broadband access.13 Expanded access to the Emergency Broadband Benefit or the Connected Care Pilot Program may improve access for patients living in poverty. Further, telehealth technology should now be viewed as an integral component to healthcare delivery. As insurers start reverting telehealth reimbursement to prepandemic norms, liver professional societies (e.g., American Association for the Study of Liver Diseases) should advocate for continued and expanded telehealth reimbursements. For example, we must advocate for pay parity across video and nonvideo telehealth appointments to ensure that those with suboptimal or absent internet connection can still receive remote hepatology care. Further, to better ensure those living in remote regions can continue to receive hepatology care, we must advocate for continued reimbursement across state lines. The future of healthcare is digital. Expanding telehealth technology to those who have physical barriers to seeing a liver specialist in person is but one opportunity to overcome geographical disparities in liver disease. However, much work remains to ensure that such technology is available to those with the greatest need. The authors lay out the problem with disparate broadband access; now we must act.